Only in America

The phrase “only in America” was one I heard frequently as a child. It was often said in a light-hearted manner, sometimes with a faux Eastern European accent, but always with a deep reverence for what my parents believed to be it’s central truth: that the United States was a special place. Its unique blend of opportunity, freedom and compassion had allowed our family to go from poor immigrants to prosperous professionals in 2 generations. What a country!

I thought of that phrase this morning in a darker, ironic sense, as I read about a middle-aged couple in Tennessee who were struggling to figure out how to afford health insurance. The husband is retired, and the wife makes a solid salary at a small company. Yet they found that they were trapped by their circumstances: they were too young for Medicare, earning too much for Medicaid, not offered health insurance by the wife’s employer, and not able to afford the market rate for an individual policy on the ACA exchange. After considerable study they decided that they had two options – they could get a divorce, which would allow the husband to qualify on the basis of his lower income for an insurance subsidy, or the wife could take a substantial pay-cut, which would make them eligible for an exchange subsidy. They chose the latter, and actually appear to have come out ahead, since the subsidy was greater than the after-tax difference in her pay before and after.

What is wrong with this picture? Here are a few things that come to mind:

The health insurance “system” is clearly broken if it creates incentives, no matter unintended, to dissolve marriages and earn less

There is a huge “complexity tax” that we are all paying to prop up the Rube Goldberg arrangements of the current health insurance marketplace. How much time, effort and anxiety were spent by this couple to figure this out? For those of you fortunate enough to have employer-provided benefits, how much time did it take you to do your benefits enrollment? Did you get it right?

All this is playing out while Congress cut taxes on the most fortunate in our society

One could portray the Civil war as a conflict in values between Lincoln’s rising corporate state and the Southern agrarian interests who depended on slave labor.

I question whether the Civil War accomplished much of anything. The situation of the blacks was actually worse after the war, when 4 million freed slaves roamed the southern countryside without resources because they were never compensated for 200 years of bondage.

The KKK was formed as a white protection organization. When Union armies withdrew no one was present in the South to enforce civil rights.

Forced convict labor was much worse for the blacks who now could be worked to death with impunity. At least under slavery the owners had an incentive to preserve the lives of their slaves.

I live on the margins in a wealthy Colorado city teeming with homeless people.

The bus system is utilized by two major classes of folks: university students and some faculty and staff, and homeless. The city gives the homeless free bus passes and lets them use the buses as mobile shelters.

The dichotomy of lifestyles is jarring and probably makes the wealthy and privileged very uncomfortable. They don’t realize that persistent policies by both Democrats and Republicans gutted housing allowance, social welfare programs and mental health care for these people now filling the streets.

The American elites are behaving like sharks in a feeding frenzy. I don’t think they actually need more money; I think their true purpose is to starve the Federal government of funds. The wish for only three departments to remain: Treasury, Justice and Pentagon. America is behaving like a failing Empire. All production will soon shift to China and India and the only people comfortable here will be those with paper assets. Everyone else will be expendable.

We clearly are living in a Banana Republic run by Banana Republicans.

The Democrats became a party of the liberal elites completely out of touch with reality for the vast majority of Americans. Trump’s Repubs don’t care about these people either but are skilled at exploiting their anger and deflecting their attention from the economic heist the leaders are engaged in.

I believe soon we will see street fighting like in 1930s NAZI Germany when Hitler’s brown shirt thugs beat dissenters up in the streets.

The elites also will increasingly appeal to religious leaders to pacify the growing discontent and to promise pie in the sky. That’s why you have the seeming paradox of Trump being supported by redneck whites, Orthodox Jews and Muslim sheiks.

I have read that the real problem in our system is that doctors decided way back to outsource billing responsibilities to insurance companies, saving the docs the hassle of unpaid bills etc. They didn’t realize that soon insurance overheads would consume 30% of health care costs and that the companies would interfere in every aspect of health care.

Is there credibility to this claim?

It seems to me that “insurance” is the wrong concept for our health care. To me insurance is a policy against an unforeseen event with unmanageable costs. But going to the doctor for an annual physical and other forms of maintenance should not be deemed “unforeseeable”. It should be part of every day planning for one’s health and wellbeing.

How did all this get tucked under the concept of “insurance”?

In Britain the system is called the NHS National Health System. No insurance at all. A system of care for the well being of the entire population.

I suspect that there is some kind of sick infatuation in America with gambling. Two of the most powerful Right donors are casino magnates. There seems to be a mentality in this country that it’s ok if 999 suffer so long as one has a shot at the big payoff.

i wonder if “insurance” fits into this mentality of chance, odds, payoffs etc?

Author

This blog isn’t about sharing information; it’s about starting conversations. And since good conversations require good listening, I decided to call this blog “Auscultation.” Ira Nash, MD, FACC, FAHA, FACP

The views expressed here are solely the personal views of Ira Nash, MD and do not necessarily represent the policy or position of Northwell Health Physician Partners, Northwell Health or any of their affiliates, employees or physicians.

About Ira Nash, MD

Ira Nash, MD is the Executive Director of Northwell Health Physician Partners, and Senior Vice President of Northwell Health, and a professor of Cardiology and Population Health at Hofstra Northwell School of Medicine.